Health inspection·February 29, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one (Resident #165) of three residents reviewed for hospitalization was coded correctly on the minimum data set (MDS) at discharge. Residents Affected - Few Findings included: A review of Resident #165's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses included but not limited to Unspecified dementia, unspecified severity, with psychotic disturbance, muscle weakness (generalized), Unspecified lack of coordination, chronic kidney disease, stage 3b, bipolar disorder, unspecified, Major depressive disorder, recurrent, moderate and generalized anxiety disorder. A review of the Discharge - Return Not Anticipated Minimum Data Set (MDS) dated [DATE] revealed under Section A- Identification Information A. 2105 Discharge Status Resident #165 was discharged to 04 Short Term General Hospital. A review of progress notes revealed the following: - A progress note dated 01/23/2024 showed, Family has decided to transfer resident to [another local long term care facility] memory care unit on Friday 1/26/24 between 1 and 2 PM. Unit manager is aware. - A progress noted date 01/26/2024 showed, Resident sitting quietly in B wing TV room. Pt [patient] alert with confusion. Pt [patient] compliant with medications and care from staff. No s/s [signs or symptoms] of pain or distress noted. No negative behaviors noted at this time. Resident continues with PT [Physical Therapy] services. Resident scheduled to be transferring to another facility today between 11:00 am-12:00 pm. Will chart when pt leaves facility. No further issues noted at this time. - A progress note dated showed, Resident left facility via transport arranged by insurance to [local long term care facility] in [city, state]. [Family Representative] present as pt [patient] was being transferred. Report given to [Family Representative]. [Family Representative] will return back to facility for pt's [patient's] things tomorrow 1/27/24. - A progress note date 01/27/2024 showed, The [Family Representative] came to the facility, to collect resident's personal belongings, TV and mount. She stated, Thank you for all you have done for my mother. - A progress note dated 01/29/2024 showed, Social services spoke with [Family Representative]and Page 1 of 5 105515 105515 02/29/2024 Solaris Healthcare Plant City 701 N Wilder Rd Plant City, FL 33566

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few memory care unit to ensure all needs were met. They ensured all belongings were received and there were no issues since arrival. Resident is settling in nicely. Encouraged family and resident to reach out with any questions or concerns. No concerns at this time. Will follow up if needed. During an interview on 02/28/24 at 10:04 a.m., Staff A, MDS Coordinator/RN stated Resident #165 was discharged to another skilled nursing facility for their memory care unit. Staff A reviewed the Discharge Return Not Anticipated MDS dated [DATE] MDS that showed Resident was discharged to the hospital. Staff A stated that the MDS was coded wrong as Resident #165 was not discharged to the hospital but rather discharged to another skilled nursing facility. Staff A stated she would have to amend the MDS to reflect the correct discharge. 105515 Page 2 of 5 105515 02/29/2024 Solaris Healthcare Plant City 701 N Wilder Rd Plant City, FL 33566

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to revise a care plan to reflect a resident's condition for one (Resident #151) of 33 sampled residents. Findings included: Review of Resident #151's Face Sheet revealed he was admitted to the facility on [DATE] from an acute care hospital. His medical diagnoses included dementia, psychosis, anxiety disorder, encephalopathy, major depressive disorder, and insomnia. An observation conducted on 02/26/24 at 10:08 a.m. revealed Resident #151 sitting in a chair in the C-wing hallway with his eyes closed. An interview was conducted on 02/26/24 at 10:33 a.m. with Staff B, Licensed Practical Nurse (LPN). She said Resident #151 was pleasantly confused but redirectable. She said he did not push on doors or talk about leaving he will just walk the unit. The exit doors at the end of the hallway were not used and they had alarms on them if they were opened. A review of Resident #151's Elopement Risk assessment with a an observation date of 1/9/2024 and a 1. Prior to admission, did patient have a history of elopement or exit seeking behavior? No 2. Has patient exhibited wandering or exit seeking behavior in the last 90 days? No 3. Select patient's mobility status. Independently Ambulatory 4. Has patient exhibited new behavior that would cause concern related to wandering exit seeking or safety? No 5. Was or is patient resistive to Nursing Home placement. No 6. Does patient verbally express desire to leave center or go home? No A review of Resident #151 care plan last reviewed on 1/9/24 revealed the following: Problem: I tend to wander aimlessly up and down the halls going to and from door to door. I push on door at times, I Have severe Dementia with cognitive deficits and confusion. I am at risk for elopement .Goal: I will not harm myself or others due to my wandering through next review date. Interventions included the following: Ensure temperature is comfortable in my room Ensure proper fitting of my clothes and shoes Ensure lighting is adequate for me 105515 Page 3 of 5 105515 02/29/2024 Solaris Healthcare Plant City 701 N Wilder Rd Plant City, FL 33566

F 0657 Assist me to bed when fatigued Level of Harm - Minimal harm or potential for actual harm Be calm and self assured Provide opportunities for positive interaction, attention - stop and talk with me passing by. Residents Affected - Few Intervene as needed to protect the rights and safety of others; approach me in a calm manner; divert my attention, remove me from situations and take me to another location as needed Administer and monitor the effectiveness and side effects of medications ordered for me - see physicians orders and MAR [Medication Administration Record] Address wandering behavior by walking with me; redirect me from in appropriate areas; engage in diversional activity. Reinforce positive behavior Provide me with no-confrontational environment for care Report to my physician changes in my behavioral status. Place my photo at from lobby and on all wings so others will recognize me and redirect me. An interview was conducted on 02/28/24 at 9:37 a.m. with the Director of Nursing (DON). She said, the resident was a wanderer and would wander around the unit. He was not exit seeking and he did not push on exit doors. She said, I don't think he has ever even been off the unit. She reviewed the elopement risk assessment dated [DATE] and reviewed Resident #151's wander care plan and said I think the care plan needs to be updated. The DON said she had been in the building for 14 years and she had not known Resident #151 to push on doors. She said we should monitor him because he was confused and he walked the unit but he was not exit seeking. An interview was conducted on 02/28/24 at 9:50 a.m. with Staff A, Minimum Data Set (MDS) Coordinator. She said, I have been in this position for about five years. I don't feel like he [Resident #151] is an elopement risk, he does not try to exit seek, I have not seen him pushing on doors, he does not try to follow people out of the doors. He uses the door as a boundary, he walks to the end of the hall turns around, walks down another hallway, and turns around. She said she would not want to remove the portion of the care plan where it says he is at risk for elopement because although his elopement assessment says he's not at risk I want the staff to know if the door is open that he usually uses as a boundary he is at risk to keep going out the unit door. She confirmed the care plan should have been revised to remove I push on door at times. She said care plans are reviewed quarterly, yearly, and with any change. Review of the facility's Care Plans- Comprehensive policy reviewed on 1/30/24 revealed the following: Policy Statement An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 105515 Page 4 of 5 105515 02/29/2024 Solaris Healthcare Plant City 701 N Wilder Rd Plant City, FL 33566

F 0657 Policy Interpretation and Implementation Level of Harm - Minimal harm or potential for actual harm .8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition changes. Residents Affected - Few 105515 Page 5 of 5